Suction curettage for removal of retained intrathoracic blood clots and pleural lesions.

OBJECTIVE: To develop a thoracoscopic technique for correcting and/or removing an intrathoracic disease process using our existing operating room equipment and without a "small thoracotomy." METHODS AND PROCEDURES: Fifty-eight patients from October 1994 to April 1998 were prospectively studied. All were undergoing procedures involving the removal of a suspected benign (or infectious) pleural process or a retained blood clot. Three or four thoracic ports were used in all cases. Straight and curved suction curettage cannulae (with finger valve attachment) ranging from 8 to 16 French were available for use. Intermittent variable suction (between zero and 60 mm Hg) was used in all cases. Dependent upon the size and adherence of the lesion to be removed, the pressure was determined by the surgeon and regulated by the circulating nurse in the room. In each case, a trap system was used for retrieval of the specimen. One lung ventilation was used in every case, and when suction was used one of the ports was kept "open" to allow room air to enter the chest cavity.
RESULTS: All patients in our series had their procedures completed without the need for any kind of open thoracotomy. Pre and postoperative diagnosis concurred in all 10 patients, and no complications occurred (specifically, no injury to the lung tissue or chest wall structures). Operative time ranged from 45 minutes to 180 minutes with a mean of 75 minutes. In all cases of a hemothorax, a cell saver system was used for an average of one unit of blood autotransfused per case.
CONCLUSIONS: New techniques do not always require the purchase of new equipment. Tight hospital budgets are forcing surgeons to rely on redefining uses of instrumentation already available in solving surgical problems. We believe that the use of this instrumentation will provide another avenue for surgeons to successfully complete a procedure thoracoscopically without the need for a thoracotomy. It is through multidisciplinary conferences such as the Society of Laparoendoscopic Surgeons that ideas such as this are propagated.

INTRODUCTION

The use of thoracoscopy in the management of intrathoracic lesions has been greatly increasing over the last several years. However, the development of new instrumentation for thoracoscopy has been relatively slow when compared to the development of instrumentation for laparoscopic surgery. The cost incurred in new product development is not feasible to most instrument manufacturers taking into consideration the number of surgeons performing thoracoscopy versus those performing laparoscopic procedures. Faced with this challenge, we have subsequently devised a new application of existing instrumentation to perform thoracoscopic surgery, which we feel is valuable for thoracic surgeons to use during thoracoscopy.

METHODS

From October 1994 to December 1997, 58 patients (42 males and 16 females) were treated with thoracoscopic surgery. Age of the patients ranged from 15 to 82 years. The indications for surgery are summarized in . All patients undergoing thoracoscopic surgery had double lumen endotracheal intubation and were placed in either the right or left lateral decubitus positions depending on the side of the pathology. Three or four ports were used for performing the procedures. Standard laparoscopic instrumentation was used, as well as, 0 or 30 degree 10 mm laparoscopes. The suction machine used was the Berkely vacuum curettage system by Cabot Medical, Langhorne, Pennsylvania. Suction curettage cannulae ranged in size from 8–16 French of the straight and curved variety with a finger valve attachment so the suction could be controlled by the surgeon, as well as intermittent variable suction between 0–60 mm of mercury, which can be adjusted by the circulating nurse. demonstrate the set-up. All procedures were able to be completed thoracoscopically. A cell saver apparatus was used when bleeding was anticipated for the retrieval and recirculating of shed blood. All specimens were retrieved in the trap system that was part of the suction apparatus. One of the ports was always kept “open” to allow room air to enter the chest cavity during suctioning.

Operating room set-up.

Intraoperative view.

RESULTS

All patients in our series had their procedures completed without the need for any kind of thoracotomy. Pre and postoperative diagnosis concurred in all patients, and no complications occurred (specifically no injury to lung tissue or chest wall structures). Operative time ranged from 30–150 minutes with a mean of 75 minutes. In all cases of a hemothorax, a cell saver system was used for an average of 1 unit of blood autotransfused per case. Postoperative course in all patients averaged from 2–7 days depending on the underlying pathology. Ten cases had air leaks noted in the postoperative period that all resolved by discharge. One patient required re-exploration for a staple-line dehiscence on the second post-operative day that was corrected thoracoscopically. Minor wound infections developed in two of the four patients operated on for empyema.

DISCUSSION AND CONCLUSIONS

New techniques do not always require the purchase of new equipment. Tight hospital budgets are forcing surgeons to rely on redefining uses of instrumentation already available in solving surgical problems. Review of the literature has revealed that thoracoscopy has been used in treatment of disease processes ranging from malignant pleural effusions like a diagnosis of underlying intrathoracic pathology[1,2] to recurrent pneumotho-races,[3,4] empyema,[5,6] retained clot (trauma),[7--12] and lung volume reduction. Using the “advantage” of thoracoscopy as opposed to laparoscopy, where no insufflation to minimal insufflation is required in the chest cavity, we are able to use high-flow suction apparatus to remove intrathoracic pathology with the use of our revised instrumentation.[13-17] In cases where our procedure was done for staging of a malignancy or the high probability of there being an intrathoracic malignancy, work-up revealed that these lesions were most likely metastatic and, therefore, the procedure was only done to establish a tissue diagnosis or palliation.[18-20] It is our current principle that malignancies that are potentially resectable will not be performed as a thoracoscopic procedure. We believe that the use of this already available instrumentation will provide another avenue for surgeons to successfully complete a procedure thoracoscopically without the need for a thoracotomy. Initially, it was through multidisciplinary conferences, such as the Society of Laparoendoscopic Surgeons, that ideas such as this were propagated. We encourage our colleagues to continue discussion amongst their specialties to exchange ideas that will help expand the utility of instrumentation that is already available and help maintain cost-effective care in our specialties.

Table 1.

Indications

Indications for Surgery	58 Patients
Recurrent Pneumothorax	21
Pleural Lesion	12
Paranchymal Lesion	10
Suspected Benign
Staging Procedure	7
Empyema	4
Retained Clot	4